Transcription of List All Applications Pertaining to Refund Below
1 HSMV 73644 (Rev 07/11) Division of Motorist Services Refund Request A Refund is requested for the Following (Check proper box/boxes) License Fee Examination Fee Service Fee FR Re-fee ID Card Fee Other _____ List All Applications Pertaining to Refund Below : Date (s) Applied _____ Office # _____ Audit # (s) _____ Fees Paid _____ _____ _____ _____ _____ _____ _____ _____ _____ Justification for Refund (Explain Fully): Name Address Driver License Number Date of BirthTotal RefundOffice ID Examiner ID Date Customer s Signature Instructions: Please complete, print and sign this form. Mail form to: Division of Motorist Services Box 5775 Tallahassee, FL 32314-5775
